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FOR OFFICE USE: ----------------- --------------------------------------- ------ ----------------------------------------- ---- -- 'APPLICATION FOR SANITATION PERMIT Permit No. ..A.//..2 Z `--- ----- --------------------------------------------- (Complete in Duplicate) ------ ....... This Permit Expires 1 Year From Date Issued Date Issued ._.................... Application is hereby made to the San Joaquin Local Health District for a permitjo.construct and install the work herein described. This application is made in compliance with County Ordinance No. 549.�-"," -r7_# Q 5'&i�Z30 --/0 ' .Y. - JOB ADDRESS A 'LOCATI Owner's Name..: ...... SQA. . -�'---- ----•-• ---- ---------c- ------ ---------- --•--- Phone..-------------------.............. --- Address-.......-t -..... -- } Contractor's Name - ---- ------ Phone Installation will serve: Residence ❑ -Apartment House-E]- Commercial ❑, Trailer Court,A Motel ❑ Other ❑ Number of living units: §___ Number of bedrooms -------- Number of baths ........ Lot size ......... __._._.___---_ Water Supply: Public system ❑ Community system ❑ Private-0 Depth-to,Water•Table ________ ft. Character of soil to 4i,-depth of 3 feet: Sand ❑ Gravel ❑ Sandy_Loam (X Clay Loom x❑,,,Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,dafe _______________ ) No ❑/ New Constru ton: Yes'[1 'No'❑ FHA/VA: Yes ❑ No ❑ r i TYPE OF INSTALLATION "AND.:SPECIFICATIONS:..,.,, (No septic+angor cesspool peemi#ed if public sewer is available within 200 feet:)"""'t —I 4 i Septi Tank: Distance from nearest well---!Q.....Distance from foundation._..._"'...._......Material_________ __ __ _ _ __ ....... No. of com artments�"_'.r_ Size... :!. y v� y�V,, P t _: .../r- ,� _Liquid depth.T -- ------------- CaPacitY auT�' (,J e Dispo ni Field: Distance from nearest well----s ___._;,_�Distanct from foundation_____'_-___:__-__{Distance to nearest lot line.....,....... Number of lines______________________I__ ___ Length of each line+!-_�-__ -----.IWidth of trench_____ _�._� �r ,-.. Type of filter material._:___ _ _____Depth of filter material____.�l _.._______._Total length-------- _--________________________ _ i na P �„ r Seeps a Pit: Distance to nearest well--___IfD___.__ ....Distance from f undation____-_• __-__-_-.Distance to nearest lot line---- x [ Number of'pits.... g --.Size: Diameter_._....d4v---_----.Depth_...-•4S-------------- p' _________ Linin material__ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material____..____--___-_-_-_-----__•-__-____ ❑ Size: Diameter-_1---------------------------------Depth------------------- -•-------- ---------------------Liquid Capacity-------------------_------- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_______•__________________________________ ❑ Distance to nearest lot line---------------------------------------------------------•-----.-------.-------------•----•-------••-------------------------•••-------------- Remodelingairing- es ihe):-------------------------------------------•---------•-•--------------------•----•--•-•------.._..------•---------------------...----------•-............ .......................--------------------------------------------------------------------------------------------------------------- ------------------------------------------------------- ------------------------------ I ------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----------------- 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules nd regulations of the San Joaquin Local Health District. op----- -and/or Contractor)(Signed) e By--------------- ------ --- - ------ --------------------------------------------------(Title)---------------------------------------- --- ------ (Plot plan, showing size of lot, location of system in elation to wells, buildings, etc., can be placed on reverse side}.- - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -----------------------------------•----------------------- DATE..Y. r ` ------------------ REVIEWEDBY----------------------------------------------------------------------- ------------------------------------------------------ DATE----------- BUILDINGPERMIT ISSUED------------------------------------------------ -•----------------------------•-------------------- DATE-------•-----••-------------------------•----- ._..._...._._. Alterations and/or recommendations:-'------------------------------------- --------------------------------------------------------••----•----...-----••----------------------------------------- I . i ----------------------------------------------- •---...--------------------------------------------------------------------------------•-------------- -••-•----•---•-------------------------------••---------------------- i } ---- T' = ^6 Z------ ----------------------- FINAL INSPECTION BY:-- - -- ----- -- ------------------- Date_Date.-.- -- -• -- _ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street a 300 West Oak Srreet 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California EB 9 REVISED 8-59 2M 5-61 ATLAS -